After years of neglect, India’s oldest public health programme in spotlight

Bobby Ramakant, CNS Correspondent
India’s first (and oldest) public health programme was on sexually transmitted infections (STIs) since it became an independent republic. But as the years rolled on the programme lost its steam. Only recently it was merged with the National AIDS Control Programme (NACP) up to district level and with National Rural Health Mission (NRHM) for sub-district programmes.
Responses to STIs have been very sketchy, with HIV, which is one of the STIs, getting significantly more attention than a range of other STIs whose disease burden is no less alarming. HIV is also transmitted through non-sexual routes and even its response in India has gaps. Dr Chander Puri, former Director of National Institute for Research in Reproductive Health (NIRRH – an Indian Council of Medical Research (ICMR) institute), and Pro Vice Chancellor (Research) of Mahatma Gandhi Mission Institute of Health Sciences, which co-hosted the “International Conference on Emerging Frontiers and Challenges in Management and Control of STIs and HIV”, said that over 170 International and Indian delegates are attending this conference.

Dr Puri stressed that “prevalence and disease burden of STIs is lot more than HIV. Globally 1 million people acquire STIs every day as per the World Health Organization WHO. 500 million people get sick by 1 of the 4 most incident STIs.”

Globally it is estimated that over 290 million women who are infected with human papilloma virus (HPV) are at risk of developing cervical cancer. Some STIs increase the risk of HIV acquisition 3-4 fold. STIs are not only responsible for cervical cancer but also at times for infertility. “We need to increase investment and improve programmatic response to STIs to curtain disease burden due to STIs” said Dr Puri.

Dr Atmaram H Bandivdekar, Deputy Director and senior scientist at NIRRH, ICMR, who is also one of the key organizing secretaries of this conference, said: “There are number of STIs affecting not only adults but also teenagers and even children. Many a times it is known as maternal transmission but the transmission may have happened through paternal route too.”

With every passing day, STIs are adding to the disease burden. We need to understand how STIs transmission occurs, what are the mechanisms, what clinical practices are out there in responding to STIs, what levels of stigma is associated with STIs, among other factors, so that programmatic response to STIs can be improved. “This conference aims to address these issues” said Dr Bandivdekar.

“Millennium Development Goals (MDGs) Related to Reproductive Health” publication was released in the opening ceremony of this conference. One of the key lead contributors, Dr Balaiah Donta, who is a senior scientist at NIRRH, ICMR, and is also one of the organizing secretaries of this conference, said: “It was observed that while we were moving towards meeting some of the MDGs but progress is not uniform across geographical spread of our country.” Dr Donta said that although India is close to meeting HIV-related MDGs (of halting and reversing the epidemic) yet we need to do much more effort to address HIV in key affected populations such as men who have sex with men (MSM), transgender people, sex workers, injecting drug users (IDUs), among others, so that MDGs can be met. He said that progress on meeting infant mortality related MDGs was too far behind.

Dr Atmaram H Bandivdekar added: “HIV is so highly variable as compared to other STIs so may be this is why no cure available so far.” Perhaps that is why it is a major challenge to develop any preventive microbicide, vaccine or other biomedical prevention methods to stop transmission of HIV. Dr Bandivdekar was the lead author of “Emerging Frontiers and Challenges of HIV/AIDS Research” said that this publication contains scientific research papers and will be a useful resource to develop other strategies to control HIV. This publication was released by Dr VK Subbaraj, Secretary of the Department of AIDS Control, Ministry of Health and Family Welfare, Government of India.

Dr Sudhir N Kadam, Vice Chancellor, MGM Institute of Health Sciences (a deemed university), said: “Exact data on STIs is not available. On an average in India, 6% of people in 15-49 years age group are estimated to have STIs. STIs are concentrated in poorest and most marginalized sections of society.” He highlighted that India tops the world in cervical cancer deaths with 26% cervical cancer related deaths occurring in India alone! Dr Kadam also stressed on the government to come up with a programmatic response to control STIs and assured of full cooperation of his institute.

Dr VK Subburaj, who heads India’s HIV programme, said that currently over 750,000 people are receiving free antiretroviral therapy (ART). Although STI programme was India’s first public health programme after independence yet it lost its steam. When National AIDS Control Programme began its operations, STI programme was merged into it to function up to district level. STI programming for below district level became a part of National Rural Health Mission. Dr Subburaj stressed on effective HIV prevention options as prevention is better than cure – and there is no cure for HIV presently except putting people on a lifelong ART. 60% of AIDS budget is spent on prevention since the very beginning said Dr Subburaj. He said that currently over a million people living with HIV are registered with national programme but only a little over 750,000 get ART. Rest are told to come back to the clinic when CD4 count goes below 500 (previously CD4 count cut-off was 350). Resource constraint is of course there but it also makes public health sense to boost up prevention as well. Dr Subburaj said that 57% reduction in number of people living with HIV who are getting identified every year is a result of sustained focus on prevention apart from scaling up treatment and care alongside. 250,000 new PLHIV were reporting to the programme annually earlier but now that number has come down to 115,000.

He also stressed on HPV vaccination for young and adolescent girls and annual screening of women above 30 years of age for cervical cancer. “It takes about 10 years for HPV infection to become a full blown case of cervical cancer. That is why screening is so important to nip cervical cancer related deaths.” He also stressed for prevention, treatment and care of Hepatitis B virus (HBV) and Hepatitis C Virus (HCV) both of whom are also transmitted sexually (apart from other blood borne routes).

One of the luminary medical scientists of the country, Dr NK Ganguly, also addressed this conference. Dr Ganguly is the former Director General of ICMR and Chairperson of Scientific Advisory Committee of MGM Institute of Health Sciences. He reflected on three major breakthroughs that shaped commendable HIV response of India over the years.

The National AIDS Control Organization (now Department of AIDS Control) needs to be congratulated, said Dr Ganguly. NACO led interventions did not only stop the epidemic but also have halved the numbers of new infections in the country, said Dr Ganguly. But India has to do a lot more with robust programmatic interventions to deal with infections such as Hepatitis B and Hepatitis C. 45 million people are estimated to have Hepatitis B Virus (HBV) and 2.5 million with Hepatitis C Virus (HCV) in India.

Dr Ganguly recollected that when first HIV test came positive in India in 1986, there was lot of denialism. There was hardly any political will to support a surveillance to find out what was the HIV incidence in the country, so that appropriate programmatic response can come forth. Despite no political will, then Director General of ICMR and visionary scientist Professor Vulimiri Ramalingaswami pushed all ICMR institutes across the country to begin HIV surveillance. Without data on HIV rates in the country it was trying to 'hit in the dark'. Later ICMR’s HIV surveillance network was handed over to the National AIDS Control Organization when it came into existence.

Dr Ganguly recognized that another landmark contribution of ICMR to boost India’s HIV response was setting up of National AIDS Research Institute (NARI). A network of research institutes emerged. Initial reports of very high HIV incidence among injecting drug users (IDUs) also came in very early in 1990s when Dr Roger of UCLA who was working on diarrheal surveillance reported that 50% of young IDUs had HIV as well.

Highlighting contribution of research in HIV response Dr Ganguly felt that NARI study was a game changer in terms of risk perception, which showed majority of women who tested positive for HIV were married and monogamous

Underlining another landmark in India’s HIV response Dr Ganguly said that “ICMR took an important decision with NACO to stop parent to child transmission of HIV.” At that time there were no guidelines from WHO on breastfeeding of infants born to HIV positive mothers so India learnt its lessons on PPTCT the hard way.

let us hope this ICMR led conference will help strengthen prevention, diagnosis, treatment and care of all STIs in the country.